DiversityNursing Blog

By Marilynn Marchione

By Angela Hill

Shyanne Reese prefers to call herself a "conqueror" rather than a survivor of breast cancer. She revels in her personal triumph, defeating the foe that threatened her life in 2008, and is now moving forward with poise and purpose.

However, Reese didn't always feel so confident. In fact, as an African-American, she says cultural myths long held her back from seeking treatment or even giving herself breast exams.

"Culturally, it's been taboo to discuss cancer in the African-American community, so a lot of women suffer in silence or don't seek treatment when they should," said Reese, 59, who works in the insurance industry and volunteers as a community health advocate for the Women's Cancer.

Cancer "conqueror" Shyanne Reese, who volunteers for the Women's Cancer Resource Center, is photographed in Oakland on Sept. 12, 2012. (Kristopher Skinner/Staff) Resource Center in Oakland. She reaches out to women at churches and health expos, leading the center's Sister to Sister support group for black women and even helping them navigate the health care system. "And I had my own personal battles. My mother had instilled in me a belief that it was wrong or sinful to touch myself, so I had never done self exams."

 Indeed, as health advocates work to draw attention to the disease for all women during October's National Breast Cancer Awareness Month, many point to recent studies -- such as one from Sinai Urban Health Institute in Chicago, which examined statistics from 25 major U.S. cities -- that confirm a fact physicians and advocates have known for decades: while Caucasian women have a higher incidence of breast cancer, women of color are more likely to die from it, chiefly because of cultural, social and economic factors that lead to late detection and treatment.

"There's a history of silence around cancer in the African-American community," said Peggy McGuire, executive director of the Women's Cancer Resource Center, which provides programs for low-income black women and Latinas. "Part of the problem is that they see themselves as the caregivers of the family and put themselves second. There's a reluctance to admit they are ill."

In addition, many say there's embarrassment and guilt -- as though a woman has done something to cause the disease. That combined with a "what I don't know won't hurt me" mentality is a recipe for avoidance behavior.

"There's also distrust of the medical community," McGuire said. "And, of course, poverty is the most significant factor because women likely lack health insurance, have poor nutrition -- even just living in neighborhoods with violence is a factor. The stress accompanying that has a significant effect on immune systems."

At Latinas Contra Cancer in San Jose, advocates have encountered unique cultural barriers for Latino women.

"For Latinas, cancer is often seen as a death sentence. It's kind of, 'If I've got it, that means I'm gonna die, so I don't want to know,' " said Ysabel Duron, Latinas Contra Cancer founder, KRON-TV news anchor and a cancer survivor/conqueror. "And there are religious barriers. Some see it as a punishment from God, that they must have done something wrong and deserve it. Or they'll say their husbands won't let them get a checkup -- no other man should be touching them.

"These are the things we try to break through. It's really about getting into those communities and literally taking them by the hand and navigating them through this."

Angelica Nuno, 24, of Oakland, did just that with her aunt a few years ago, helping her with translations, filling out forms, sitting with her in the doctor's office. Nuno now volunteers as a community health advocate for the Women's Cancer Resource Center.

"I saw how hard it was for my aunt with the language barrier, so I wanted to help," she said. "A lot of women in that situation are scared to even approach a hospital. They don't know you can get free mammograms and support."

While the medical community is learning more about societal issues affecting Latinas and African-American women with breast cancer, even less research has been done for Middle Eastern, Pacific Islander or other groups, Duron said.

"They're where African-American and Latinas were 15 years ago as far as research goes," she said.

Advocates in nonprofit assistance organizations hope health care reform will address some of the disparities in mortality rates by increasing cultural sensitivity training for mainstream care providers, Duron said. In the meantime, much of that kind of support falls to independent groups. And to volunteers like Reese.

By 2008, Reese was making big changes in her life. She had reached her weight-loss goal, dropping 101 pounds. And through her increasing education about women's health, -- which she said she had to go outside her family to find -- she had finally become comfortable with self breast exams.

"Something felt different," she said. "I didn't know if it was because of the weight loss. But going in to get it checked out -- I still felt embarrassment and guilt, like maybe I had caused this myself somehow because of carrying the weight for so long."

When her cancer was diagnosed, the same week she was laid off from her job, she was asked at the hospital if she wanted to have a social worker as a support person. She said no.

"It was all just overwhelming, and when I did decide I needed support, I wanted someone who looked like me, but there was no one available. It was so embarrassing to say that I needed help that way. African-American women are taught they don't need help and suffer isolation sometimes. So the challenge was to say, yes I want help."

Reese, who had surgeries on both breasts, has been cancer-free for nearly three years now.

"For me, breast cancer has been a gift," she said. "I knew I had a purpose in life, and it's finally been revealed -- to do what I do now, to reach out and help other women."

Anyone who has been in the nursing field for an extended period of time will tell you that a lot has changed. In fact, the twentieth century brought – literally – a technological “invasion” to nursing. 

According to Kaplan Nursing, from small advances, like digital thermometers, to sophisticated strides, like laser surgery, health care as a whole has been on quite a rollercoaster - and nurses have been along for the ride.

Medical advancements and information technologies of the twentieth century have not only changed the face of the nursing – they have become part of the intricate fabric of the field. 

But what are the technologies responsible for this monumental transformation?

One nursing professional – and author of a site called The Nurse Lady- offers these 19 technologies that changed nursing forever.

1.Electronic IV monitors

There was a time when IVs had to be administered with a nurse’s constant attention to ensure a steady flow. Manual IVs were highly sensitive to a patient’s movement and the flow of the IV could be sped up or slowed to a crawl by a subtle movement. To prevent this, nurses had to directly administer an IV from beginning to start. With the advent of IV pump infusion and electronic monitoring, nurses are freed up to initiate an IV and allow a machine to monitor and regulate the process. If there is an error, the system tries to correct it, and otherwise contacts the nurse via remote monitoring.

2.The Sphygmomanometer

The sphygmomanometer is simply a fancy term for electronic blood pressure cuffs that also measure heart beat rate automatically. Gone are the days when a nurse had to measure blood pressure manually. According to one nurse, this is the technological change that makes the biggest daily difference.

3.Information management

As computer technologies become the primary means of managing patient information, nurses have had to adapt their record-keeping practices and increase their computer skills. Nursing informatics is a specialty that has emerged, combining IT skills and nursing science.

4.The portable defibrillator

Manual CPR can only do so much and for the longest time this was the only method available to many nurses for reviving someone’s heart. Now, even school nurses stand a fighting chance to save the life of a person whose heart has failed. The few minutes after heart failure are critical, and the portable defibrillator allows for immediate resuscitative action.

Sturdy, portable IT devices

Tablet computers and mobile wireless computer stations are now a standard part of the day-to-day methods of delivering care to patients. Charts are updated continuously, in real time, providing nurses with immediate access to essential patient information.

6.Readily accessible base of information

Wireless Internet connections quickly make reference materials available. This can prove very helpful for diagnosis, especially when using a resource like WebMD.

7.The sonogram/ultrasound

Ultrasound devices provide nurses working with pregnant patients the ability to see inside the womb. Ultrasound has been nothing short of revolutionary in the field of Women’s Health and pregnancy, allowing nurses and doctors to noninvasively identify the health of the baby throughout pregnancy. Now, with the advent of 4-D ultrasound, unprecedented detail is available for diagnosing fetal well-being. In addition to pregnancy monitoring, sonogram technology also offers many other new diagnostic advances such as the ability to easily identify cancer tumors in the bladder, and to tell whether the liver is enlarged.

8.Local wireless telephone networks

These systems significantly reduce communication delays. Not only is this type of communication technology being utilized between nursing staff, but also between patients and staff, changing the dynamics of the relationship between patients and their nurses.

9.Hands-free communication devices

Hands-free devices such as Vocera’s Call Badge provide the ultimate in communication while a nurse is engaged in active patient care or associated tasks.

10.Communications options

It is not uncommon for patients and nurses (and doctors) to communicate via e-mail or even web cam; a practice that is becoming common for parents of children in neo-natal intensive care units.

11.Patient remote monitoring

In addition to high-tech and ultra-sensitive vital signs monitoring equipment, web cams and other technologies make the close monitoring of multiple patients much easier, changing how environments are staffed and operated.

12.RFID technologies

RFID-enabled devices make monitoring hospital assets easier, ranging from drugs and equipment to records and patients. They also enhance safety and security with less effort and lower long-term cost.

13.Compact, portable medical devices

Combined with portable IT and communication equipment, these small, high-tech types of devices allow well-equipped nurses to take their skills on the road. They can travel to patients’ homes and treat conditions that once had to be treated on an in-patient basis.

Neo-natal nursing advancements

New, more affordable portable devices for the care of tinier and more health-compromised babies.

15.Drug management technologies

High-tech systems of medication retrieval and delivery, such as bar coding and verification, have greatly reduced the potential for dangerous error. Infusion equipment advances have made the delivery of slow-administer drugs much easier, with computerized machines able to control dosages and rates.

16.Configurable nursing environments

Configurable work spaces increases efficiency and safety, reduces stress, and prevents accidents and injuries.

17.Learning technologies

The availability of individual and off-site learning opportunities and degree programs, via specialized software and online classes, allows for more rapid career advancement.

18.Video conferencing

The ability to interact with nursing professionals throughout the world, through such means as video conferencing, offers advantages and opportunities like never before, both in terms of the further development of the nursing profession and the continued improvement in patient care outcomes.

19.The blogosphere 

Medical technologies have brought changes to the process of life and death and the role of the nurse. The Internet allows nurses to share their experiences and feelings. As technology transforms the profession, nurses adapt and change as well. The big question is: What will the rest of the twenty-first century bring?

By DAN FROSCH

The debate pits nurse anesthetists, who specialize in administering anesthesia and maintain that they are well equipped to treat patients on their own, against anesthesiologists, who are physicians and say nurses lack the necessary training.

The dispute dates to a 2001 change in Medicare and Medicaid regulations, allowing states to opt out of a requirement that nurse anesthetists be supervised. And it is part of a broader turf war over how much power nurses should have in treating patients.

“With the removal of the requirement, it actually increases access to health care for citizens in rural Colorado,” said Scott K. Shaffer, president of the nurse anesthetists association in Colorado, one of 17 states that have chosen to allow nurses to deliver anesthesia without supervision.

Since Colorado’s rural hospitals were exempted from the supervision regulation in 2010, Mr. Shaffer said, some medical facilities that may not have employed anesthesiologists have been able to attract specialists because there is no longer a concern about who would administer anesthesia or supervise.

“Now patients don’t have to turn around and go to Colorado Springs or Denver when they can be taken care of in their hometown,” he said.

In Colorado, however, the issue has prompted a legal battle. In 2010, anesthesiologist and medical societies filed a lawsuit in state court asserting that allowing nurse anesthetists to deliver anesthesia without supervision was not consistent with state law, a requirement for opting out of the federal rule.

But a judge dismissed the case, ruling that the legislature had indeed intended for the practice to be permitted. The medical groups appealed last May.

“There is a very different background between nurses and physicians in both education and training,” said Dr. Randall Clark, a spokesman for the Colorado Society of Anesthesiologists. “Anesthesia is a very complex and technically demanding area of medicine that, at its core, needs to be either performed by a physician or supervised by one.”

Dr. Clark said that despite concerns about health care access, his group believed that there were more anesthesiologists than nurse anesthetists currently working in the nearly 50 rural Colorado hospitals affected by the opt-out decision. And in those instances when a hospital does not have a staff anesthesiologist, he said, it is still safer to have a physician on hand to supervise lest complications arise.

At a state appeals court hearing in Denver on Tuesday, Assistant Attorney General LeeAnn Morrill argued that Colorado law clearly permitted doctors to delegate medical functions to advanced practice nurses. Joseph J. Bronesky, a lawyer for the anesthesiologist society, said the law was murkier.

The case is being watched closely by national nursing and anesthesiologist groups, for whom the debate has become increasingly contentious. Each side has promoted studies backing its perspective.

The American Society of Anesthesiologists cited a 2000 study financed by the federal Agency for Healthcare Research and Quality, which found that the presence of an anesthesiologist helped prevent deaths in cases where an anesthesia or surgical complication had occurred.

Conversely, the American Association of Nurse Anesthetists referred to a study it financed that was published in Health Affairs in 2010. It examined Medicare data from 1999 to 2005 and found no evidence that opting out of the supervision requirement resulted in increased inpatient deaths or complications.

“When it comes to giving anesthesia, certified registered nurse anesthetists and anesthesiologists are identical,” said Christopher Bettin, a spokesman for the nurse anesthetists group. “There are no differences in what they learn, the drugs and equipment they use and the standards of care they follow.”

Colorado is not the only state where the dispute over nurse anesthetists has ended up in the courts. Last month, the California Society of Anesthesiologists petitioned the State Supreme Court to review its lawsuit over California’s 2009 decision to opt out of the supervision requirement. The group’s suit, initially filed in 2010, has so far been unsuccessful.

“Our concern is patient safety,” said Dr. Kenneth Y. Pauker, president of the California group. “Is an independent nurse able to tender the same quality of care as an anesthesiologist or an anesthesia care team? What happens when things get really complex and you have to call upon all your years of medicine?”

Jana Du Bois, chief counsel for the California Hospital Association — which has sided with the nurses, as has its Colorado counterpart — said that rural areas in California continued to struggle to recruit and retain specialists.

“If there aren’t enough physicians and a woman in labor comes in, you can’t say, ‘We have to wait until next week to get an anesthesiologist,’ ” she said.

The Family Health Clinic of Carroll County, in Delphi, Ind., and its smaller sibling about 40 minutes away in Monon provide full-service health care for about 10,000 people a year, most of them farmers or employees of the local pork production plant. About half the patients are Hispanic but there are also many German Baptist Brethren. Most of the patients are uninsured, and pay according to their income — the vast majority paying the $20 minimum charge for an appointment. About 30 percent are on Medicaid. The clinics, which are part of Purdue University’s School of Nursing, offer family care, pediatrics, mental health and pregnancy care. Many patients come in for chronic problems: obesity, diabetes, hypertension, depression, alcoholism.

What these clinics don’t offer are doctors. They are two of around 250 health clinics across America run completely by nurse practitioners: nurses with a master’s degree that includes two or three years of advanced training in diagnosing and treating disease. By 2015, nurse practitioners will be required to have a doctorate of nursing practice, which means two or three more years of study. Nurse practitioners do everything primary care doctors do, including prescribing, although some states require that a physician provide review. Like doctors, of course, nurse practitioners refer patients to specialists or a hospital when needed.

America has a serious shortage of primary care physicians, and the deficit is growing. The population is aging — and getting sicker, with chronic disease ever more prevalent. Obamacare will bring 32 million uninsured people into the health system — and these newbies will need a lot of medical care. According to the American Association of Medical Colleges, the United States will be short some 45,000 primary care physicians by 2020.

The primary care physicians who do exist are badly distributed — 90 percent of internal medicine physicians, for example, work in urban areas. Some doctors go to work in rural areas or the poor parts of major cities, treating people who have Medicaid or no insurance. But they are few.

In part it’s the money. Primary care doctors make less than specialists anywhere, but they take an even larger financial hit to treat the poor. Particularly in the countryside — even with programs that offer partial loan forgiveness, it’s very hard to pay off medical school debt treating Medicaid patients, much less those with no insurance at all.

And the job of a primary care doctor today is largely managing chronic disease — coordinating the patient’s care with specialists, convincing him to exercise or eat better. Poor patients can be a frustrating struggle. Compared with wealthier patients, they tend to have more serious diseases and fewer resources for getting better. They are less educated, take worse care of themselves and have lower levels of compliance with doctors’ orders. Very few people start medical school hoping to do this kind of work. Those who do it may burn out quickly.

It might seem that offering the rural poor a clinic staffed only by nurses is to give them second-class primary care. It is not. The alternative for residents of Carroll County was not first-class primary care, but none. Before the clinic opened in 1996, the area had some family physicians, but very few accepted Medicaid or uninsured patients. When people got sick, they went to the emergency room. Or they waited it out — and then often landed in the emergency room anyway, now much sicker.

Just as important, while nurses take a different approach to patient care than doctors, it has proven just as effective. It might be particularly useful for treating chronic diseases, where so much depends on the patients’ behavioral choices.

Doctors are trained to focus on a disease — what is it? How do we make it go away?

Nurses are trained to think more holistically. The medical profession is trying to get doctors to ask about their patients’ lives, listen more, coach more and lecture less — being “patient-centered” is the term — in order to better understand what ails them.

“I’ve been out of nursing school since 1972 and I still remember that when faculty members finished talking about the scientific parts of the disease they would talk about the psycho-social part,” said Donna Torrisi, the executive director of the Family Practice and Counseling Network, which has three clinics in Philadelphia. “It’s not about the disease, it’s about the person who has the disease. While in the hospital you’ll often hear doctors refer to a patient as ‘the cardiac down the hall.’”

Younger doctors are no doubt better at this than their older peers. But the system conspires against them. The 15-minute appointment standard in fee-for-service medicine — which pays doctors according to how many patients they see and treatments they provide — makes it unlikely that doctors will spend time discussing a patient’s life in any detail. Physician reimbursement places a zero value on talking to the patient. But nurse practitioners are salaried, giving them the luxury of time. At the Family Health clinics, appointments last half an hour — an hour for a new diabetic or pregnant patient.

Jennifer Coddington, a pediatric nurse practitioner who is a co-clinical director of Family Health Clinics, said that she spends a lot of time teaching patients and their families about their diseases and how to manage it. “We want to know socially and economically what’s going on in their life — their educational level, how are they making it financially,” she said. “You can’t teach patients if you’re not at their educational level. And if a patient can’t afford something, what’s the point of trying to prescribe it? He’s going to be non-compliant.”

A physician might suggest that a patient lose weight and hand him a diet plan — or refer him to a nutritionist. At the Family Health clinics, nutrition counselors — graduate students at Purdue — will sit down with patients to talk about the specific consequence of their diet, and suggest good foods and how to cook them, Coddington said. “When you don’t have enough money to buy fruits and vegetables, so you go to the dollar menu at McDonald’s — we help those people put planners together for the week.”

Data has shown that nurse practitioners provide good health care. A review of 118 published studies over 18 years comparing health outcomes and patient satisfaction at doctor-led and nurse practioner-led clinics found the two groups to be equivalent on most outcomes. The nurses did better at controlling blood glucose and lipid levels, and on many aspects of birthing. There were no measures on which the nurses did worse.

Nurse-led clinics can save money — but not always in the obvious way. Many are cheaper than comparable physician-led clinics. Suzan Overholser, the business manager of the Family Health clinics, said that their cost per patient was $453 per year — lower than the Indiana average for similarly federally qualified clinics (all the others physician-led) of $549. But nurse-led clinics aren’t always cheaper. Coddington examined published studies of clinic costs and found that in some cases, nurse-managed clinics had slightly higher per-patient costs than traditional clinics.

Although nurses are paid less than doctors (Medicare reimburses them at 85 percent of what it pays doctors,) nurse-led clinics are often very small, and so don’t have the variety of practitioners necessary to keep a clinic running at full capacity. They also serve the most difficult and expensive patients.

The biggest financial benefit, however, likely comes from offering patients an alternative to the emergency room. Coddington’s review cites studies showing large savings in paramedic, police, emergency room and hospital use. A traditional clinic in an underserved area would do that, too, of course — it’s just that nurses tend to go where doctors won’t.

There are about 150,000 nurse practitioners in America today. The vast majority practice in traditional settings — only about a thousand are in nurse-managed clinics. One reason these clinics are rare is that they may equal traditional clinics in health care, but not in business success.

Nurse-managed clinics have to overcome regulatory and financial obstacles that traditional clinics don’t face. Powerful physicians’ groups such as the American Academy of Family Physicians oppose allowing nurses to practice independently. “Granting independent practice to nurse practitioners would be creating two classes of care: one run by a physician-led team and one run by less-qualified health professionals,” says a paper from the A.A.F.P., citing the fact that doctors get more years of education and training. “Americans should not be forced into this two-tier scenario. Everyone deserves to be under the care of a doctor.”

Only 16 states and Washington, D.C., allow nurses complete independence. In other states, some of the restrictions are bizarre — in Indiana, for example, nurse practitioners may do everything doctors do, with two exceptions: they can’t prescribe physical therapy or do physicals for high school sports.

Jim Layman, the executive director of the Family Health clinics, said he thought that nurse practitioners cared for the majority of Medicaid patients in Indiana. But if you look through Medicaid records, you’ll find only doctors — nurses are not allowed to be the primary caregiver of record. So the Family Health clinics, like others, employ a physician off-site from 4 to 6 hours a week who uses electronic health records to examine a sample of cases and consult when necessary. Medicaid is billed in his name.

It is not easy for nurse-run clinics to win status as a Federally Qualified Community Health clinic, which would allow them to get federal grants. This is largely because most come out of universities, and most universities don’t want to cede control to the community — a requirement for this status. Purdue decided it would, and the Family Health clinics qualified in 2009. Before that, they received some money from the state, and raised the rest from local March of Dimes, United Way and Chamber of Commerce donations, plus fund-raising dinners and auctions. This was enough to support just one full-time provider at each clinic. Getting F.Q.C.H. status allowed them to hire more staff and move the Carroll County clinic into a modern new building — and probably saved them from collapse. “It would have been very difficult for us had we not gotten F.Q.C.H. status,” said Coddington. The Affordable Care Act — Obamacare — did authorize $50 million for five years for nurse-managed clinics. So far 10 clinics have gotten a total of $15 million.

In some ways, the nurse practitioner-managed clinic is a throwback to the small-town family practice, when your doctor asked about the schoolyard bully and your dad’s unemployment. Among the many changes needed in how America values and reimburses health care, it’s important to encourage and support these clinics. They may be old-fashioned, but that doesn’t mean they should be financed with bake sales.

By RICHARD PÉREZ-PEÑA

In just a few years, technology has revolutionized what it means to go to nursing school, in ways more basic — and less obvious to the patient — than learning how to use the latest medical equipment. Nursing schools use increasingly sophisticated mannequins to provide realistic but risk-free experience; in the online world Second Life, students’ avatars visit digital clinics to assess digital patients. But the most profound recent change is a move away from the profession’s dependence on committing vast amounts of information to memory. It is not that nurses need to know less, educators say, but that the amount of essential data has exploded.

“There are too many drugs now, too many interactions, too many tests, to memorize everything you would need to memorize,” says Ms. Eland, a specialist in uses of technology. “We can’t rely nearly as much as we used to on the staff knowing the right dose or the right timing.”

Five years ago, most American hospital wards still did not have electronic patient records, or Internet connections. Now, many provide that access with computers not just at a central nurse’s station but also at the patient’s bedside. The latest transition is to smartphones and tablet computers, which have become mandatory at some nursing schools.

“We have a certain set of apps that we want nursing students to have on their handheld devices — a book of lab tests, a database of drugs, even nursing textbooks,” says Helen R. Connors, executive director of the Kansas University Center for Health Informatics. Visiting alumni, she says, are shocked to see students not carrying physical textbooks to class.

But technology carries risks as well. So much data is available that students can get overwhelmed, and educators say that a growing part of their work is teaching how to retrieve information quickly and separate what is credible, relevant and up-to-date from what is not. (Hint: look for the seal of approval of Health on the Net.)

They also worry that students rely too much on digital tools at the expense of patient interaction and learning.“There’s a danger that having that technology at the point of care at the bedside creates a misperception that students don’t need to know their stuff,” says Jennifer Elison, chairwoman of the nursing department at Carroll College in Helena, Mont.

“I get worried when I hear about nursing programs that want to replace the person-to-person clinical experience with increased hours with simulation,” she says. “We hear sometimes that it feels to patients that the computers are more important than they are.”

Then there’s the patient privacy issue in the era of blogging, Facebook and Twitter. How to properly use social media has become standard in the curriculum, thanks in part to what is known in nursing circles as “the placenta incident.” Four nursing students at a community college in Kansas posted Facebook photos of themselves with a human placenta. The students were expelled in 2010, and later reinstated, but the episode showed how murky the boundaries of privacy and professionalism can be. The National Council of State Boards of Nursing recently published guidelines on social media.

“That is the new hot issue now,” Ms. Elison says. “That’s been hard, because this is a generation that immediately hits that send button.”

By DAVID BORNSTEIN

In 2010, 5.9 million children were reported as abused or neglected in the United States. If you were a policy maker and you knew of a program that could cut this figure in half, what would you do? What if you could reduce the number of babies or toddlers hospitalized for accidents or poisonings by more than half? Or provide a 5 to 7 point I.Q. boost to children born to the most vulnerable mothers?

Well, there is a way. These and other striking results have been documented in studies of a program called the Nurse-Family Partnership, or NFP, which arranges for registered nurses to make regular home visits to first-time low-income or vulnerable mothers, starting early in their pregnancies and continuing until their child is 2.

We tend to think of social change as more of an art than a science. “What’s unique about Nurse-Family Partnership is that the program was studied in what’s considered the strongest study design, and it showed sizable, sustained effects on important life outcomes which were replicated across different populations,” explained Jon Baron, president of the Coalition for Evidence-Based Policy, a nonpartisan group. “This is very unusual. There are probably only about ten programs across all areas of social policy that currently meet that standard.”

What that means, notes Baron, is that if policy makers replicate the program faithfully they can be confident that it will change people’s lives in meaningful ways — improving child and maternal health, promoting positive parenting, children’s school readiness and families’ economic self-sufficiency, and reducing juvenile delinquency and crime.

NFP is not a new idea — it’s almost 40 years old — but after decades of study the program, which has assisted 151,000 families, has the potential for broader impact, thanks to the Affordable Care Act’s Maternal, Infant, and Early Childhood Home Visiting Program, which provides $1.5 billion for states to expand such programs.

Done well, it could be among the best money the government spends. Investments in early childhood development produce big payoffs for society. (A 2005 RAND study estimated that NFP provided $5.70 in benefits to society for every dollar spent.) But there’s an important concern: home visiting programs are not all effective. When carefully studied, only a few have been shown to reduce the physical abuse and neglect of children. Among the programs that meet the government’s standard for funding, there are large variations in evidence of impact (pdf). Policy makers and proponents of home visiting would do well to pay attention to the specific elements in the Nurse-Family Partnership’s model that account for its success.

NFP was founded by David Olds, who directs the Prevention Research Center for Family and Child Health at the University of Colorado Health Sciences Center. Early in his career, Olds worked in a day care center in Baltimore because he believed that quality preschool attention would help disadvantaged children succeed in life. What he began to see was that, for some kids, it was already too late to make big gains. If children had been abused or neglected or exposed to domestic violence, or if their mothers had abused drugs, alcohol or tobacco while pregnant, their brains could have been damaged in ways that limited the children’s abilities to control impulses, sustain attention or develop language.

Olds developed NFP in the early 1970s. He conducted his first large study in 1977, in Elmira, N.Y., a semi-rural, mostly white, community with one of the highest poverty rates in the state. The program produced strong results. Follow-up studies would reveal that, by age 19, the youths whose mothers received visits from nurses two decades earlier, were 58 percent less likely to have been convicted of a crime. In the 1980s and 1990s, Olds spread the work to Memphis and Denver and subjected the program to more randomized study with populations of urban blacks and Hispanics. The results continued to be impressive. In 1996, NFP began wider replication; the model is now being implemented by health and social service providers in 40 states.

As Olds published his results, the idea gained momentum, but the imitations did not remain faithful to NFP’s approach. “People adopted all kinds of home visiting models and used our evidence to make claims,” he recalled. In the early 1990s, for example, the federal government, inspired in part by NFP, began a $240 million program to train paraprofessionals, rather than nurses, to make home visits to low-income families with young children. NFP also experimented in Denver, using paraprofessionals (trained from the communities they served) in place of nurses for a subset of families.

In both cases, paraprofessionals didn’t get the same results. When it came to improving children’s health and development, maternal health, and mothers’ life success, the nurses were far more effective. In the federal program, paraprofessionals produced no effects on children’s health or development or their parents’ economic self-sufficiency.

What’s special about nurses? For one thing, trust. In public opinion polls, nurses are consistently rated as the most honest and ethical professionals by a large margin. But there were other reasons nurses were effective. Pregnant women are concerned about their bodies and their babies. Is the baby developing well? What can I do for my back pain? What should I be eating? What birthing options are available? Those are questions mothers wanted to ask nurses, which was why they were motivated to keep up the visits, especially mothers who were pregnant for the first time.

Nurses had more influence encouraging mothers to delay subsequent pregnancies, Olds explained. They could identify emerging complications more promptly, and they were more successful at getting mothers to stop or reduce smoking, drug or alcohol use. This is vital. Prenatal exposure to neurotoxicants is associated with intellectual and emotional deficits. It can also make babies more irritable, which increases risks of abuse. (A mother who was abused herself is more likely to misinterpret an inconsolable baby’s crying as “bad behavior.”)

“A lot of the young mothers have had some pretty terrible early life experiences,” says Olds. “It’s not uncommon for them to have been abused by partners or never have had support and care from a mother. Their lives haven’t been filled with much success and hope. If you ask them what they want for themselves, it’s not uncommon for them to say, ‘What do you mean?’”

A big part of NFP’s work is helping them answer this question.

Consider the relationship between Rita Erickson and Valerie Carberry. Rita had had a methadone addiction for 12 years and was living from place to place in Lakewood, Colo. She found out she was pregnant; a parole officer told her about NFP. “I’d burned bridges with my family,” Rita told me. “I was running around with the wrong people. I didn’t have anyone I could ask about being pregnant.” In the early months, Valerie had to chase her around town, Rita recalled. “I was worried she might say, ‘This is too much hassle. Come back when you have your act together.’ But she stuck with me.”

Over the next two years, they embarked on a journey together. “I had a zillion questions,” Rita recalled. “I was really nervous at first. I had lived most of my adult life as a drug addict. I didn’t know how to take care of myself.” On visits, they discussed everything: prenatal care, nutrition, exercise, delivery options. After Rita’s daughter, Danika, was born, they focused on things like how to recognize feeding and disengagement cues, remembering to sleep when the baby sleeps, how to manage child care so Rita could go back to school. For Rita, what made the biggest impression was hearing about how a baby’s brain develops — how vital it was to talk and read a lot to Danika, and to use “love and logic” so she develops empathy. Once Valerie explained that when babies are touching their hands, they’re discovering that they have two. “To me that was really amazing,” Rita said.

This month, Rita is graduating from Red Rocks Community College with an associate degree in business administration. She’s going to transfer to Regis University to do a bachelors degree. Her faculty selected her as outstanding graduate based on leadership and academic achievement — and she was asked to lead the graduation procession and give one of the commencement speeches. Danika is thriving, Rita said. Recently, she came home from preschool and announced:  “Mommy, I didn’t have a good day at school today because I made some bad decisions and you wouldn’t be proud of me.” (She had pushed another child on the playground.) As for the NFP, Rita says that it helped her recover from her own bad decisions. When Valerie came along, she needed help badly. “I didn’t care about my life. I didn’t care about anything. I never ever thought I would have ended up where I am today.”

“When a woman becomes pregnant whether she’s 14 or 40, there’s this window of opportunity,” explained Valerie, who has been a nurse for 28 years and hasworked with more than 150 mothers in NFP over the past seven. “They want to do what’s right. They want to change bad behaviors, tobacco, alcohol, using a seat belt, anything. As nurses, we’re able to come in and become part of their lives at that point in time. It’s a golden moment. But you have to be persistent. And you have to be open and nonjudgmental.”

Beyond the match between nurses and first-time moms, there are multiple factors that make NFP work. (NFP has identified 18 key elements for faithful replication.) The dosage has to be right: Nurses may make 50 or 60 visits over two and a half years. The culture is vital: It must be non-judgmental and respectful, focusing on helping mothers define their own goals and take steps towards them. The curriculum should be rigorous, covering dozens of topics — from prenatal care to home safety to emotional preparation to parenting to the mother’s continuing education. Nurses need good training, close supervision and support, and opportunities to reflect with others about difficult cases. And, above all, data tracking makes it possible to understand on a timely basis when things are working and when they are not.

By limiting our understanding of diversity in nursing to matters of race and religion, we risk excluding other cultural groups, warns Arabella Sinclair-Penwarden

Issues of diversity enjoy a high profile in nursing today, from the RCN’s continuing emphasis on the importance of valuing diversity, to training in this area in both pre- and post-graduate contexts. Defined as ‘the state or quality of being different or varied’ in Collins English Dictionary, the word has accumulated various different interpretations, not all true to the original.

I asked several colleagues what ‘diversity’ meant to them. ‘Respecting people of different races,’ said one. ‘Being aware of other people’s religions and faiths,’ said another. Still another commented that it was ‘to do with treating each patient as an individual’.

These are examples of applying the term constructively and, typically of nursing, in a wholly practical manner. Yet by restricting our definition to matters of race or creed, we risk isolating the term and omitting cultural groups that fall under neither heading.
When I was asked to take on the role of diversity link nurse in my department, I was intrigued by the potential of the role. You see, there was no precedent, no shoes to fill. The role was entirely new.

Our trust had a comprehensive policy relating to the different spiritual beliefs of patients, and I had no desire to replicate what had been written. But I had read about Deaf culture – and there did not seem to be a great deal of awareness about it.

Deaf people are not always perceived as a specific cultural group. Indeed, there is confusion about the terms related to an absence of hearing. What, for example, is the difference between a patient being deaf and Deaf? Between being deafened and hard of hearing? Information is both scarce and sparse. Terms may be used interchangeably and research can be confusing.

It is common practice to capitalise the ‘D’ in ‘Deaf’ when writing about the culture and the children and adults that make up its members. The term ‘deafened’, or ‘deaf’ with a small ‘d’, or ‘hard of hearing’ is frequently used to describe someone who has acquired hearing loss. This may also be referred to as being ‘post-lingually deaf’, meaning those whose loss developed after the acquisition of spoken language.

Anecdotally it has been noted that terms can be used inconsistently, and sometimes incorrectly, even by healthcare workers.

Yet, when such a lack of clarity exists, it is unsurprising that confusion regarding dealing with patients with hearing loss should follow.

The term ‘Deaf community’ has demographic, linguistic, psychological and sociological dimensions, and this is underlined by the description of sign language as ‘a minority language’. It therefore seems wholly appropriate to include the needs of people who identify themselves as culturally Deaf when discussing diversity issues.

As nurses and midwives we are bound by the code of conduct set down by the NMC. Thus, we are – or should be – aware not only of the need to respect each person within our care as an individual but also to be wary of discriminating against them. Yet discrimination can take many forms. Direct discrimination is defined by the government as when a person is treated ‘less favourably because of, for example, their gender or race’. Indirect discrimination is when ‘a condition that disadvantages one group more than another is applied’.

By being ignorant of the discrete needs of culturally Deaf patients we risk indirectly discriminating against our own patients, whether by not providing an interpreter when one is required, or by assuming that a pre-lingually Deaf patient will be able to lip-read fluently.

We are not expected to be fluent in British sign language, nor to be fully au fait with the finer nuances of Deaf culture. But, in view of a 2004 RNID statistic suggesting that 35% of Deaf and hard of hearing people have been left unclear about their condition because of communication problems with a GP or nurse, neither can we afford to be lackadaisical. Awareness of these issues is the key to individualising care – and that is something that we are required to do.

New research suggests that ethnic minorities in Scotland are less likely to get cancer than white Scots.

According to data gathered by researchers from the University of Edinburgh, the rate of cancer in Indian men living in the country was 45.9% of that of white Scots, whereas the rate among Chinese men was found to be 57.6% in comparison.

The investigation, which examined ethnic variations in the rate of cancer using figures from the Scottish Cancer Registry, the NHS and the 2001 Scottish Census, revealed the lowest rate of lung cancer to be among Pakistani men living in Scotland, at 45% of the rate for white Scots.

People from Scotland’s Pakistani community were found to have the lowest rates for colorectal, breast and prostate cancers

Professor Raj Bhopal, of the University of Edinburgh’s Centre for Population Health Sciences, said: “Cancer rates in migrants and their children tend to become similar to those in the local population. Despite their long residence in Scotland, however, ethnic minority groups have lower rates of cancer than the white Scots.

“There is much to learn here that could benefit the whole population, which could improve everyone’s health.”

The results were published in the journal BMJ Open.

From diversityinc.com

In the fall of 2005, Alister Martin seemed the most unlikely candidate for Harvard Medical School. Laid up in the hospital with “my face so swollen my mother didn’t recognize me,” he says, the high-school senior was recovering from a brutal gang attack. The situation had escalated to a point that law enforcement advised Martin’s mother, a Haitian immigrant, to pull her son from Neptune (N.J.) High School to avoid further trouble.

So Martin’s mom secured a $15,000 loan and sent her son to the private Bollettieri Tennis Academy in Florida, where he completed his GED online while practicing 16 hours a day. Martin’s drive and unwavering desire to become a physician pointed him to Rutgers University’s Office for Diversity and Academic Success in the Sciences (ODASIS), whose Access-Med program prepares promising Black, Latino and other undergrads from underrepresented and economically disadvantaged groups for careers in medicine.

Four years later, Martin graduated from Rutgers with a 3.85 GPA and will begin Harvard Medical School this fall. “A miracle happened,” says Martin.

Each year, ODASIS serves roughly 500 at-risk undergrads, and nearly 800 of them have graduated since the program’s founding in 1985. Among the ODASIS class of 2009, 86 percent were accepted to medical school, up from 70 percent in 2007.

Still, Black, Latino and American Indian med students are rare. Three years ago, more than 40,000 people applied to medical school in the United States, with Blacks, Latinos and American Indians making up only about 15 percent of the applicant pool, reports the Association of American Medical Colleges (AAMC), while comprising about one-third of the population. That same year, only 8.7 percent of doctors were from these underrepresented groups, according to a study published in the Journal of Academic Medicine.

The latest AAMC data shows only slight improvement: Among the 42,269 med-school applicants in 2009, only 16 percent were Black, Latino or American Indian. And this disparity extends beyond the potential physician pool—a mere 6.9 percent of people from underrepresented groups ended up as dentists in 2007, only 9.9 percent were pharmacists and just 6.2 percent were registered nurses.

But it’s critical that people from underrepresented groups be recruited into healthcare and other science, technology, engineering and math (STEM) fields because it will increase the quality of care for those groups and spur innovation. Black, Latino and American Indian/Pacific Islander physicians are nearly three to four times more likely than whites to practice in underserved communities, reports the AAMC.

The dearth of diversity in all STEM professions is what inspired the launch of ODASIS. In 1986, when the initiative first began, only one Black student from Rutgers was accepted to medical school, and he eventually became a radiologist.

STEM-Enrichment Success

ODASIS is a rigorous program that offers four years of step-by-step supplemental instruction, academic enrichment and career advice designed to increase the pipeline of underrepresented talent in all STEM fields. The program is managed by Trinidad native Dr. Kamal Khan, a tireless instructor and caring mentor. He ensures that a four-year academic plan is developed for each incoming freshman so he/she stays on track and pursues the appropriate opportunities.

As a result, these students, often the first in their families to attend college, gain self-confidence. Before ODASIS, says Martin, “I never really believed in myself.”

Academic customization and an integrated-learning approach have helped make ODASIS a success. As part of the Access-Med program, for example, Khan formed collaborative relationships with local healthcare institutions to provide students with research training, professional learning and hands-on experience. Most unique to this pipeline program is the seven-month MCAT (Medical College Admission Test)/DAT (Dental Admission Test) prep course.

Khan often starts working with students who have been identified as having an interest in the sciences the summer prior to their first semester at Rutgers. To facilitate the transition for these incoming freshmen, Khan developed a five-week summer prep program to expose students to basic math and chemistry that allows them to earn college credits toward their degree. This summer, with financial support from Merck & Co., Khan and his team are working with 25 students to help hone their basic math skills “so they can hit the ground running” when they enter college.

“Students were coming in not prepared to take science courses,” he says. “They didn’t have the basic college math to take a college science course. So [we'd have] to support them in the basics. And then by the time they finished the basics, they were in their second year and would say, ‘I don’t want to take the sciences. I’m going to be here forever.’”

But thanks to the support of local organizations, the Educational Opportunity Fund Central Office and Johnson & Johnson, Khan is creating a feeder pool of potential ODASIS students by working with local students as early as ninth grade. The goal: to provide laboratory exposure, SAT-prep instruction, college-admissions counseling and career advice. This year, more than 300 12th-grade students attended the ODASIS Saturday Scholars Academy, one of four separate college-prep programs Khan oversees.

“We also do workshops with parents,” he says. “We get parents very involved.”

What motivates ODASIS students to succeed? Setting high standards and being held accountable for their actions, says Khan. “If you walk into class late or you miss a session and get three red flags, you’re out of the program,” he says. “Why so strict? If you want to be a doctor and you miss the operation, someone dies. So we try to teach them to become mature at a young age.”

In addition to their regular coursework, ODASIS students are required to attend roundtable-style academic support sessions, study halls (up to 9 hours a week for freshmen), testing, motivational workshops and more. They also meet one-on-one with advisers twice a month to review their progress.

“If you’re not doing well, they will call your family,” warns Mekeme Utuk, an ODASIS graduate who just completed her first semester at Harvard Medical School.

In exchange, the students, who often come from economically disadvantaged backgrounds, appreciate the support and opportunity. “All that I could take tutoring for, I took. I thought, ‘Why not? It can’t hurt; it’s just extra practice,’” recalls Utuk, whose parents are Nigerian immigrants.

The program also teaches undergrads how to study, critical for challenging courses such as organic chemistry. “I really didn’t know how to study. In high school, I would just cram for exams. But I didn’t know how to break down a chapter and take good notes … and learn through repetition,” says Utuk. “ODASIS made me a better thinker.”